Treat-to-Target in Osteoporosis

Abstract

Treat-to-target is used to manage a variety of different chronic diseases, including diabetes mellitus, hyperlipidemia, hypertension, and gouty as well as rheumatoid arthritis. The treatment targets in these diseases might be imperfect, but they provide frameworks for clinical decisions with opportunities for improving, optimizing, and harmonizing disease management and still allowing individualized treatment decisions. As some osteoporotic patients who receive standard management may not respond satisfactorily to osteoporosis therapy or continue to have an unacceptably high risk of fracture, with a treat-to-target approach, a target is established before treatment is started. This can guide selection of initial therapy with a medication or combination of medications most likely to reach that target. Decisions to stop, continue, or change therapy can be made according to progress toward that target over time. The choice of therapy should be determined by factors that include comorbidities, cost, access to therapy, and patient preference. For patients at very high risk of fracture, especially those with a recent fragility fracture, multiple fragility fractures, or very low bone mineral density (e.g., T-score < −3.5), more aggressive treatment with an osteoanabolic agent should be considered, with consideration of patient preference and cost. This chapter will discuss the treat-to-target concept in osteoporosis and potential value of goal-directed treatment and sets out several principles to guide this approach to selecting as well as monitoring treatments.